If you’re expecting a baby, there’s a good chance you’ve wondered if you’ll have a vaginal birth or a c-section. Maybe you talked about your chance of having a c-section with your doctor or midwife. You might even wonder if a c-section is easier or safer than vaginal birth. It’s important to get the facts and understand your options, so you can be prepared to make the best decisions for you and your baby.

The reasons for having a cesarean section fall into three general categories:

Non-urgent health problems: If your doctor or midwife suggests a
c-section, chances are you have plenty of time to ask questions and find
the information you need to make the decision that is right for you.
Even if you are in labor, most situations are not urgent. However, it is
important to learn as much as you can before labor so that you are
fully prepared in case you do have to make the decision quickly. The most common non-urgent reasons why a cesarean is proposed are discussed below.

Urgent health problems: Much less commonly,
situations may arise that pose an urgent threat to the health or life of
the mother or baby. For example, if the mother is bleeding heavily (hemorrhage)
or the baby isn't getting enough oxygen, a cesarean is needed. Such
urgent situations can occur in pregnancy or while giving birth. This
Pregnancy Topic doesn't cover the small proportion of situations when
just about everyone would agree that a cesarean section is necessary.

Non-medical situations: In some cases, your caregiver may
propose, or you may be considering, a cesarean section for reasons that
have nothing to do with your health or your baby's health in the
present pregnancy. In this case, it is important to make an informed
decision with full understanding of the risks and benefits involved.

Cesarean
rates in the U.S. can range from under 10% for some caregivers and
birth settings to over 60% for others. This variation occurs for many
reasons. One is that caregivers differ in the ways that they support
women who are giving birth and in their judgment about when to
recommend surgical birth ("practice style"). C-section rates also vary
from one birth setting to another due to differences in policies and
practices. Because of this variation, your choice of caregiver and choice of birth setting can have a major impact on the type of birth that you will have.

more and more hospitals and caregivers are adopting a 'no-VBAC'
policy, and a woman who wants a VBAC may be unable to have one due to
these restrictions

loss of skills or unwillingness to offer vaginal birth to women in some situations, for example:

a woman who makes an informed choice to have a vaginal birth with a baby in breech position may have trouble finding a caregiver who is experienced and willing to attend such a birth

a woman who is expecting twins may have trouble finding a caregiver
who is experienced and willing to attend the vaginal birth of twins

the perception that a cesarean section, and especially a planned (elective) c-section, is "safe":

although cesareans are safer now than before, the surgery still
carries a broad range of short- and longer-term risks for mothers and
babies

although planned cesareans offer some advantages in comparison with
unplanned cesareans, the fact remains that surgery - planned or
unplanned - poses a series of risks in comparison with vaginal birth.

These factors can increase your chances for having a cesarean. But, the section Tips & Tools: C-Section, offers many ideas for reducing the likelihood that they will come into play in your situation.

Informed
consent is a process to help you decide what will and will not be done
to you and your body. In the case of maternity care, informed consent
also gives you the authority to decide about care that affects your
baby. The purpose of informed consent is to respect your right to
self-determination. It empowers you with the authority to decide what
options are in the best interest of you and your baby. Your rights to
autonomy, to the truth (as best as it can be known at the time), and to
keep yourself and your children safe and free of harm are basic human
rights. As the person receiving care and mother of your baby, you are
in the best position to decide what risks are important to you. (Learn more about informed consent.)

Whether
you wish to plan a vaginal birth or a cesarean section, it is important
to make this decision on the basis of complete, accurate, unbiased
information.

Below
you will find a brief discussion of the more common reasons why your
doctor or midwife may recommend a non-urgent cesarean. Less common
reasons are not discussed. If your doctor or midwife suggests a c-section and it is not an urgent situation, here are some questions to ask:

Questions to Ask

What is the benefit of a c-section for me or my baby?

What problems might happen if I continue with my plan for a vaginal birth?

How likely are those problems if I plan for a vaginal birth?

Could they still happen if I have a c-section?

What are the possible harms of a c-section?

How likely are these possible harms?

If you need more information or want to double check what you learn, you can find a comprehensive list of possible benefits and harms of c-section, along with information about how likely they are, in Best Evidence: C-Section. Your caregiver can help answer questions about this information. Once you have answers to your questions, think about what is most important to you and discuss these goals and preferences with your care provider. With these in mind, weigh the possible benefits of a c-section against the risks and make the decision that feels right for you and your baby.

Concerns about pelvic floor disorders: You may be hearing that an elective cesarean section will prevent later-life problems with leaking urine (urinary incontinence) or leaking feces or gas (bowel incontinence). The research does not support this claim.

Current research suggests that pregnancy and some commonly used maternity practices (such as routine episiotomy,
a surgical cut made just before birth to widen the opening of the
vagina) can contribute to incontinence in the period after the birth.
While research supports avoiding whenever possible maternity practices
that can harm the pelvic floor, it does not support avoiding vaginal
birth itself. In addition, studies find that birthing practices have
their strongest effects in the recovery period in the first weeks and
months after birth. These effects fall off quickly for nearly all women
and disappear for nearly all by about age 50. Incontinence in later
life seems to be related to other health and lifestyle factors such as
excess weight and smoking.

Profound fear of childbirth:
A small proportion of women, both first-time and experienced mothers,
have an extreme fear of childbirth. Certainly, almost every expectant
mother experiences some degree of fear or apprehension, but here we are
talking about something altogether different.

A series of
counseling or psychotherapy sessions during pregnancy can help many
women overcome their deep fears and give birth
vaginally. Continuous support during labor by a trained labor support
companion (doula) may be of special value to a woman in this situation. (Options: Labor Support will give you information on doulas.)
If you decide to seek counseling, be sure to get help from a trained
individual who has both good counseling skills and an understanding of
maternity issues.

If you still have deep fears of childbirth
despite counseling, you may decide to have a cesarean birth. Be sure to
talk this over with your caregiver as early as possible in your
pregnancy, and work together to help ensure the safest possible and
most satisfying birth.

Other rationales for "cesarean by choice":
As attitudes toward cesareans become more casual, and as they are
performed more "routinely," you may have thought about planning a
cesarean for reasons of convenience. For example, you may wish to
schedule your baby's birth date. Or you may think of a cesarean as a
pain-free way to give birth. Or perhaps, if labor does not go as
smoothly or as quickly as you would like, the idea of a cesarean may
appeal to you or your caregiver even if there is no clear medical
reason. Before going down this path, it is important to investigate
whether this choice truly offers you what you believe it will (such as
greater convenience or less pain). And it is also important for you to
make an informed decision with full understanding of the trade-offs
that are involved.

Previous cesarean section: Caregivers disagree about how a woman should give birth if she had a cesarean in the past. Some recommend planning a VBAC ("vee-back," vaginal birth after cesarean),
while others recommend scheduling a repeat cesarean. The concern is
with the fact that the woman's uterus has a scar, which can give way (rupture)
in a future pregnancy or labor. On the one hand, having a repeat
cesarean lowers the likelihood that a scar will open and create
problems. A recent U.S. government evidence report estimates that for
every 10,000 women who plan a VBAC, 1.4 babies will die due to scar
problems during labor. On the other hand, a surgical delivery poses its
own set of risks for mothers and babies, some of them also quite
serious. As the number of previous cesareans goes up, some of the
serious risks for any future pregnancies increase sharply.

If
you've had a previous cesarean, you would do best to learn all you can
about these and other trade-offs involved with this decision and
discuss these matters thoroughly with your caregiver before making your
decision. Be sure that your caregiver and any others who may be
attending your birth agree with your decision.

Unfortunately,
it's becoming harder to find a hospital and caregiver who will leave
the choice in your hands. If you want to have a VBAC, you may need to
search for a caregiver and hospital that will offer you this. In some
communities, this may not be available.

To help pregnant women
with a previous cesarean understand these matters and make their birth
plans, this website has a complete Pregnancy Topic called VBAC or Repeat C-Section.

Prolonged labor or failure to progress:
The length of labor varies from woman to woman. Your labor may be
short, long, or somewhere in the middle. If your labor is taking longer
than average, you may be told that you have prolonged labor.

Caregivers
vary in how they might prevent or respond to a slow labor and in their
degree of patience with a long labor. For example, some will try to
rest the uterus or stimulate stronger contractions with drugs before
turning to a cesarean. They may try such things as ensuring that the
mother is getting enough fluids or encouraging her to change positions
or walk around rather than lying flat on her back. Others will be
quicker to turn to a cesarean. As long as you and your baby are doing
well, there is no medical reason to decide on a cesarean. It's a good
idea to talk with your caregiver, well before labor begins, about how
he or she handles a long labor. Then you can think about what you might
do if you are faced with this situation.

Taking a long time to get to the point when your cervix is open (dilated) to 4 centimeters or so says nothing about your ability to birth your baby vaginally. Slow or stalled labors after that (in active labor) are more concerning, but even in these cases, most women can have vaginal births.

Having continuous supportive care from a woman trained to help women in labor (doula),
or a female friend or family member who is experienced with labor, can
help you get through a long and challenging labor. This kind of support
can also help meet your partner's needs and help your partner support
you.

Baby in breech position: Nearly all babies will take up a head-first position by the end of pregnancy. When the baby is in a buttocks- or feet-first (breech)
position, labor poses some increased risks for both mother and baby.
Because a cesarean poses its own set of risks, you may want to find a
caregiver who has hands-to-belly skills to turn the baby to a
head-first position (external version) in the last weeks of
pregnancy. Sometimes it is not possible to turn a baby with this
technique, and sometimes a turned baby will flip back to a breech position. However, most women who try this technique will go into labor with the baby in a head-first position.

Should your baby continue in the breech
position, most caregivers will recommend a cesarean. There are
important advantages to cesarean in this situation in comparison with
typical hospital ways of handling vaginal breech births, especially
lower likelihood of death or serious problems for your baby. On the
other hand, vaginal birth avoids risks of surgery for mothers and
babies in the present pregnancy and has many advantages for mothers and
babies in future pregnancies. (You can learn more about possible
problems resulting from cesarean surgery in Best Evidence: C-Section.)

If
you find yourself in this situation, you will want to discuss this
matter with your caregiver and to learn all you can about these and
other specific trade-offs involved with this decision. Be sure that you
and your caregiver agree ahead of time about your birth plan. If you
decide to plan a vaginal breech birth, it is important that
your caregiver and any others who may be attending your birth have
skills and experience with this type of birth.

Changes in the fetal heart rate:
Certain changes in the fetal heart rate may signal a problem for the baby. When the fetal heart rate is very fast, very slow, or irregular, your caregivers may be concerned about the baby's condition. In some situations, these changes are easy to correct. For example, a doctor or midwife can ask a mother who is lying on her back to move to another position, give her oxygen or fluids, or lower a high dose of synthetic oxytocin (a hormone to strengthen contractions, also called Pitocin). If this cannot be corrected and the baby is not about to be born, a cesarean may be recommended. However, electronic fetal monitors (EFM machines) often suggest that the baby is in trouble when this is not the case. Further testing can help identify which babies may need help.

Multiple births: Giving birth to more than one baby
poses unique challenges. However, no well-done research currently
supports routine delivery of twins by cesarean section. Most caregivers
will recommend a cesarean when there are three or more babies. As
always, it's important to learn as much as you can about the expected
benefits and risks of cesarean compared with vaginal birth and discuss
your individual situation with your caregiver before making your
decision. If you are having twins and want to have a vaginal birth, you
may need to seek out a caregiver who will support this.

A planned cesarean offers some advantages over an unplanned cesarean (a cesarean that occurs after labor is under way). For example, there may be fewer surgical injuries and fewer infections. The emotional impact of a cesarean that is planned in advance appears to be similar to or somewhat worse than a vaginal birth. By contrast, unplanned cesareans can take a greater emotional toll.

A planned cesarean still involves the risks associated with major surgery. And both planned and unplanned cesareans result in a uterine scar and internal scarring and adhesions. This means women with planned and unplanned cesareans face similar risks in future pregnancies and for problems related to scarring and adhesions at any time

More and more research finds that some practices used at the time of pushing increase the likelihood of pelvic floor injury. Many women experience one or more of these during vaginal birth. You can lower your risk by choosing a caregiver and birth setting with low rates of intervention. These practices include:

cutting an episiotomy

using vacuum extraction or forceps to help bring the baby out

having women give birth while lying on their backs

using caregiver-directed pushing, which is often more forceful than having the woman and her own reflexes guide pushing

A c-section might happen during labor or before labor starts (scheduled c-section). Unless there is a special situation, the woman will be awake during the surgery. Before the surgery starts, there are many preparations:

An intravenous (IV) line will be put in the woman’s arm or hand. The IV will be used to deliver fluids as well as medicines to prevent infection and bleeding problems.

An anesthesiologist will give an injection into her back to deliver spinal or epidural anesthesia, which numbs her belly and legs.

She will be positioned under the operating light on a firm, narrow bed that is slightly tilted to prevent her from lying flat on her back. Straps that are similar to seat belts will secure her on the bed.

A catheter will be inserted into her urethra to remove urine. The catheter will stay in place for about one day, and will be removed when the woman can walk on her own to the bathroom.

Oxygen will be given through a tube that fits into or over the nose.

Her belly and thighs will be shaved and cleaned with a special soap to reduce infection

Her belly, legs, and chest will be covered with sterile cloths and a curtain will be raised between her head and her lower body.

Machines will check her blood pressure and oxygen levels.

Before the surgery starts, staff will count all of the tools (clamps, scissors, etc.) and other supplies and may introduce themselves and double check the woman’s name and the reason for the surgery. These are safety checks to help prevent errors in the operating room.

During the surgery, the woman will have a support person (usually her partner or other family member) next to her on the same side of the curtain. The anesthesiologist will also be on that side of the curtain. After making sure the belly is numb, a doctor and a surgical assistant will begin the surgery. The woman may feel tugging and pulling sensations, especially right before the birth of the baby, but should feel absolutely nothing sharp. (If there is pain or a sharp sensation, the surgery should be stopped immediately so more anesthesia can be given.) It usually takes about 15 minutes from when the surgery begins to when the baby is born. Just before the baby is born, the curtain may be lowered to allow the woman and her support person to watch the baby come out. A nurse will dry and place the baby on a warming table to do a quick check on the baby’s breathing, color, and heart rate.

Once the baby is stable, the baby may be wrapped and brought to the woman to cuddle cheek-to-cheek. Some hospitals will place the baby skin-to-skin on the woman’s chest because early skin-to-skin contact after birth is healthy for babies and women. After the baby is born, the doctors will deliver the placenta, give medications to control bleeding, and stitch the uterus and other muscle and tissue layers. The skin may be closed with stitches or staples. Stitches will dissolve on their own after a couple of weeks. Staples are removed with a special tool either just before the woman goes home from the hospital or at an office visit about 1 week after the birth.

After the surgery is done, the woman is moved to a recovery room for an hour or so to be closely checked for bleeding and other problems. The baby is usually in the recovery room with the mother. This is a good time to have the baby skin-to-skin and begin breastfeeding. After the recovery room, the woman will be moved to a regular postpartum room in the hospital. The spinal anesthesia wears off around this time, and pain medications are then given by IV. The woman cannot eat or drink at first, but will soon be able to have clear liquids like juice or popsicles, then regular food. At this point the IV will be removed and the woman will take pain medication by mouth. Most women stay in the hospital about 3-4 days after a c-section.

Childbirth Connection is a national not-for-profit organization founded in 1918 as Maternity Center Association. Our mission is to improve the quality of maternity care through research, education, advocacy and policy. Childbirth Connection promotes safe, effective and satisfying evidence-based maternity care and is a voice for the needs and interests of childbearing families.